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Date run 2/15/2011 10:49:26AI SAN JO UIN COUNTY ENVIRONMENTAL HEAT `i DEPARTMENT Report*W21 <br />Run N 1273 1... Pagel <br />Facility Information as of 2/15/20 <br />Record Selection Cntena: Facility ID FA0014414 <br />'�' 1.39a� <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0011456 <br />Owner Name <br />0A4Q 4AUjBg64W <br />OwnerQ&A. <br />Owner Address <br />on nneocu o0 <br />A TLJCOT/lr.r i+n nen^+. <br />Home Phone <br />65g.Qgt�27`r <br />Work/Business Phone <br />88 <br />Mailing Address <br />8g_pgAp,SH D <br />ATME1t9@N'CA7V4b27 <br />Care of <br />{(Ai5- <br />FACILITY FILE INFORMATION <br />Facility ID FA0014414 <br />Facility Name Q6&yA AMB-BA64WC <br />Location 635 AURORA ST <br />STOCKTON, CA 95203 <br />Phone 2 `b <br />Mailing Address <br />Care ofd <br />Location Code 01 - STOCKTON <br />BOS District 001 - VILLAPUDUA <br />APN 14730004 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name{ar,AQ <br />Title <br />Day Phone 2qq 46;E.p3$8 <br />Night Phone 4gg_j502-}}§4 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0024494 <br />Mail Invoices to Facility <br />Account Name OAKLAND BAG INC <br />Account Balance as of 2/15/2011: S�499:b0 fiR PIPIMPI" <br />ProgramfElemenl and Description Record ID Employee ID and Name <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID <br />�Iffi <br />Ji MG rt%.f IY dlR. <br />U6204!" /Wvf <br />Alt Phone <br />Fax <br />EMail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility /Account <br />(circle One) <br />(Circle One) <br />Transfer to Aclive/Inaclve <br />Status Nev, Ovmer' Delete <br />2220 -SM HW GEN <5 TONS/YR PR0528613 EE0001 421 -STACY RIVERA Active Y N A <br />2244 - PACT TRANSFER RECORD - DES PR0519272 EEOOO0000 - HAZ MAT SJC DES Inactive Y N A <br />ERSC - ELECTRONIC REPORTING SURCHARGE PRO533763 Active Y N A <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned ovmer, operator or agent of same, acknowledge that all site, and/or project spec, PHS/EHD hourly charges associated vnth this <br />reality or activity Wit be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ori ince Codes and/or Standards and <br />State and/orKiaws.1 K Y� VI t.. k,Gw nWA,$•L' <br />APPLICANTS SIGNATURE: r000/ rU vV_ Date <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />PaymentT eck Number Recel <br />REHS: & VIIr� 1"W`C� Date`/Z /_Jr(_ Account out: d{1 Date <br />COMMENTS: ^ _D a /� ( Ito • 7 <br />\\eh-env\envisionVeports\5021.rpt <br />